What can digital technologies add to screening and brief

What can digital technologies add to screening and brief intervention

for alcohol use in healthcare settings?

Paul WallaceDirector, NIHR Primary Care Research Network

Professor Primary Health Care (emeritus)General Practitioner (retired)

INEBRIA: Barcelona 28th September 2012

My research interests

Alcohol: screening & brief intervention(SBI) in general practice

Application of digital technologiesin delivering health care

Digital technologies for managing alcohol problems

Grateful acknowledgements

• Nick Heather• Peter Anderson• Andy Haines• Stuart Linke• Jim McCambridge• Elizabeth Murray• Piero Struzzo

Scope of the presentation

• Digital technologies and their applications to healthcare

• Internet and mobile phone technologies for mental health & behavioural change

• Internet based alcohol screening and brief interventions

• GP facilitated access - the ODHIN and EFAR trials

• Digital technologies into the future

Digital technologies

“Through digital technologies we know far more about the people we share this small planet with than ever before. The opportunities to harness digital technologies to enable more sustainable lifestyles are everywhere: in our energy, transport and food systems, in our built environment, between machines and between individuals.”

Niall Dunne, Chief sustainability officer BT 2011

Digital technologies and eHealth

• Digital technologies fundamentally rely on the storage, transmission and processing of information in the form of binary code. This is a form of numerical notation which uses only two characters: 0 and 1.

• eHealth is the use of emerging information and communication technologies, especially the internet to improve and enable health and health care

Eng 2001

Applications of digital technologiesin health care

• Electronic care records (ECRs) • Research using ECRs and

databases• Diagnostics and imaging• Telemedicine and telecare• Virtual healthcare teams• Internet and mobile technologies

for patients

Electronic care records (ECRs)

• Increasingly common in healthcare

• Virtually universal in UK general practice

• Increasing use of coded information

• Inter-operability

GP Records Database Research

• GPRDGeneral practice research database

• THINThe Health Information Network

• Q Research EMIS system

Large volume of studies published on:Arthritis, asthma, COPD, blood pressure, heart disease, Depression, anxiety schizophrenia, Diabetes, stroke, cancer,

Parkinson’s disease, liver and renal disease

“We’re going to consult on actually changing the NHS constitution, so that the default is for patients’ data tobe used for research – unless of course they want to opt out. The end result would be that every willing patient is a research patient……that every time you use the NHS you’re playing a part in the fight against disease, at home and around the world.”

David Cameron On Life Sciences 5.12.2011

Research using ECRs and databases

Applications of digital technologiesin health care

• Electronic care records (ECRs) • Research using ECRs and

databases• Diagnostics and imaging• Telemedicine and telecare• Virtual healthcare teams• Internet and mobile technologies

for patients

Telemedicine Wallace et al Lancet 2002

Telemedicine and telecareSteventon, Newman et al BMJ 2012

Largest ever trial (£30m) of remote monitoring for patients with COPD, DM and HF

“More work needed on telehealth”

The Whole System Demonstrators showed that, "if used correctly", telehealth reduced relative death rates* by 45%, NHS resource usage by 15-20% and tariff costs by

8%.

With these striking results and the launch of the industry/NHS funded 3 Million Lives campaign,

telehealth is steaming out of its backwater into the clinical mainstream.

Telehealth has benefits for patients with long-term conditions but despite industry excitement there

are still areas of concern, argues Jeremy Wyatt

*absolute reduction of only 3.7%

Guardian Professional,Friday 6th Jan 2012

Applications of digital technologiesin health care

• Electronic care records (ECRs) • Research using ECRs and

databases• Diagnostics and imaging• Telemedicine and telecare• Virtual healthcare teams• Internet and mobile technologies

for patients

Access to the Internet

Mobile phone penetration

• Mobile cellular penetration in the developing world reached 70% at the end of 2010

• ~ 100 economies had mobile cellular penetration over 100% – and 17 economies had penetration rates above 150%.

• Two-thirds of people in Least Developed Countries now have mobile phone coverage

• African penetration up to 45.2%.BiztechAfrica - Aug. 2, 2011

Internet & mobile technologies for patients

•General health information•Long term conditions eg diabetes•Mental health:

– anxiety, – depression

•Behavioural change– smoking cessation– physical activity– diet – alcohol

Internet interventions for depression and anxiety disorders – CRD 2012

Digitally mediated interventions for smoking cessation: Internet-based – Cochrane 2010

“Results suggest that some Internet-based interventions can assist smoking cessation especially if the information is appropriately tailored to the users and frequent automated contacts with the users are ensured. However trials did not show consistent effects”.

Digitally mediated interventions for smoking cessation: mobile phones – Cochrane 2009

“The current evidence shows no effects of mobile phone-based smoking cessation interventions on long term outcome. While short term results are positive, more rigorous studies of long term effects of mobile phone-based smoking cessation interventions are needed”

The txt2stop study - Lancet 2011

Single-blind randomised trial involving more than 5,500 smokers across the UK. Quit rates for txt2stop – 10.7 per cent vs 4.9 per cent for controls at 6 months.

.Free et al, Lancet , July 2011

Behavioural change – meta-analysis of impact of design and mode of delivery • 85 interventions reviewed• Impact of interventions highly variable• More extensive use of theory

associated with larger effect sizes• Stress management and general

communication skills training have greatest impact

• Normative feedback best

*Webb et al JMIR 2010

Improved effectiveness is associated with:• more extensive use of theory (esp

Theory of Planned Behaviour)• inclusion of more behavioural

techniques• use of additional modes of interacting,

esp text messages

*Webb et al JMIR 2010

Web-based interventions for alcohol consumption – a systematic review“The current review is the first to systematically evaluate the effectiveness of such interventions and has found inconsistent results across studies. Process research suggests that web-based interventions are generally well received. However further randomized control trials are needed to investigate their effectiveness”.

Bewick et al, 2008 Preventive Medicine

Riper et al 2007 - Addiction 2007

Population based trial of 261 adult problem drinkers - web based self help intervention associated with 17% reduction in cases versus 5% in brochure control group.

Cunningham et al - Addiction 2009

Of 185 problem drinkers, those provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption (a 30% reduction in typical weekly drinking) at both the 3- and 6-month follow-ups compared to a one drink per week reduction among control group respondents.

Kypri et al - Arch Int Med 2009

RCT of proactive web-based screening and intervention. 2435 screen positive undergraduate students randomised to either Check Your Drink (CYD) or no intervention. Intervention found to reduce drinking by 6 drinks at 3m and 6m compared to 1 drink in controls

Wallace et al - PLoS 2011

On line RCT involving 7935 self selected problem drinkers allocated to psychologically enhanced website or minimally interactive site. Large and clinically significant fall in alcohol consumption across both arms at 3m (c 21u / wk) sustained at 12 m (c 25 u/wk), with parallel improvement in secondary outcomes. Psychological enhancement did not confer benefit in comparison with minimally interactive website

Conclusions from DYD RCT

• No evidence of advantage of psychological enhancement

• Striking improvements in both groups possibly due to:– regression to mean, – reactivity of assessment– Hawthorne effect– self selection by subjects already

decided to make change

• Similar results to Sobell trial of leaflet for Self Change

“Promoting Self-Change from alcohol problems: mechanisms of change in a community-based intervention”.

Sobell LC, Clinical Trials 2010

• 1-year follow up found no differences in drinking behavior between the groups

• Both groups had very substantial reductions in their drinking 1-year pre- to 1-year post-intervention.

• Many changed after seeing the advertisement, and before receiving the assessment materials

Clinician advice for behavioural change

• Clinicians are well placed to provide opportunistic behaviour counselling

• In UK, patients consult GP on average 5.5 times a year 5

• Behavioural counselling demonstrated to be cost effective for smoking and alcohol

• Key components:• therapeutic relationship • signalling by GP of interest/concern

GP facilitated access

Facilitated access by GPs* is designed to encourage use of the digital intervention, and in the UK is familiar to primary care and mental health professionals through the established model of providing facilitated access to computerised cognitive behavioural therapy programmes such as Beating the Blues and Fear Fighter

Facilitated access to eBI- a solution to the “know-do” gap for SBI?

• Facilitated access in primary care demonstrated to increase impact on users in case of websites for anxiety and depression

• Growing evidence on effectivenessof alcohol reduction websites

• GPs signposting of risky drinkers to use a website:– less time consuming than face-to-face BI– less risk of stigmatising / confidentiality issues

Pilot of implementation of facilitated access to DYD in 2 NHS primary care settings

• London primary care trusts– Kingston - GPs– Islington – integrated into IAPT (Improving

Access to Psychological Therapies) service

• Automated baseline assessment• Introduction to DYD• Provision of personalised login details• Optional follow-up phone-calls• 31 referrals in pilot

Murray et al Alcohol and Alcoholism 2012

Facilitated access to eBI: the ODHIN and EFAR trials

• International studies on eBI• ODHIN designed to determine impact of access to

eBI on GP activity• EFAR designed to :

– determine effectiveness of eBI relative to face to face intervention (EFAR FVG)

– determine effectiveness relative to simple computer printout (EFAR UKAIS)

The ODHIN trial

ODHIN: Optimizing delivery of health care interventions:

– Funded by Framework 7 EU – WP5 : Cluster RCT to evaluate impact on

SBI activity of:• education and training• financial incentives• GP facilitated access to eBI

www.healthierdrinking choices.org

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

www.healthierdrinkingchoices.org.uk

Why am I giving you this personalized referral leaflet?

I am giving you this personalized referral leaflet with your own Internet login number because I would like you to make use of the Internet based advice

resources at www.healthierdrinkingchoices.org.uk

This specially designed website which can only be used following a GP referral will help you reflect on your drinking and the possible impact it might be having on your health and wellbeing. It will also

give you the chance to make some positive choices about how you are going to drink in the future.

GP facilitated access leaflet

This leaflet gives you details of how to log on using the personalized GP referral username and password which you’ll find in the box below. Either of

these can be changed once you have logged on to create your own personal profile if you wish.

Either way, your data is completely confidential and no-one else will be able to see which information you enter on the website.

What to do now?Please find a time over the next 2-3 days when you are able to use an

appropriate way to access the Internet at home or elsewhere. Once you are online, please access the HealthierDrinkingChoices website

either by typing “healthydrinking choices” into your browser by going directly to www.healthierdrinkingchoices.org.uk

Once you have found the website, please log on using the personalized username and password below:

Your username: 01003Your password: XXXXX

GP facilitated access leaflet

The ODHIN and EFAR trials on facilitated access to eBI

• International studies on eBI• ODHIN designed to determine impact of access to

eBI on GP activity• EFAR designed to :

– determine effectiveness of eBI relative to face to face intervention (EFAR FVG)

– determine effectiveness relative to simple computer printout (EFAR UKAIS)

The EFAR trials: an integrated web-based approach to GP facilitation

• EFAR: effectiveness of facilitated access to alcohol reduction websites

• Patients invited for digitally mediated SBI using uniquely numbered practice brochures

• Brochures provide personalised code for access to e-screening: AUDIT C

• Digitally mediated GP facilitation for screen positive patients

The EFAR FVG trial

• Non-inferiority RCT of eBI vs face-to-face intervention

• Funded by Italian Ministry of Health• Led by Piero Struzzo in Region of

Friuli-Venezia-Giulia, Italy• Digitally mediated GP facilitation for

patients allocated to eBI

Digitally mediated GP facilitation

• Tailoring of message to reflect organisational and personal identity.

• Menu-driven facility including:– photographs of GP/Practice– written message from GP– audio/video recorded message from GP

Digitally mediated GP facilitation

Digitally mediated GP facilitation - with video

EFAR UKAIS

• RCT of eBI vs simple computer printout• Funded by BUPA conditional on outcome

of pilot phase of EFAR FVG• Multi-country: UK, Australia, Italy, Spain• Digitally mediated GP facilitation for

intervention group

Digital technologies SBI for alcohol - what can we conclude?

• Evidence on effectiveness of digital technologies is encouraging but not overwhelming

• Equity of access remains an issue• Acceptability for patients high but questions remain

about how healthcare professionals will react• Digital offers potential to substantially increase SBI

implementation, but more research is needed • Digital has potential to radically change the delivery of

SBI in the future

Digital technologies and the future

“The convergence of biology and

engineering is turning health care into an

information industry. That will be disruptive

but also hugely beneficial to patients”

Vijay Vaitheeswaran Apr 16th 2009Senior correspondent, expert on Global Health

Predictions……….

• Digital will be used increasingly for training and support for SBI

• Digital will be increasingly used for SBI in a wide range of settings: eg: health and social care, criminal justice, the workplace and public health

• Digital SBI will become embedded in primary healthcare through the Virtual General Practice Environment

• Inebria will play a key role as the forum for review of evidence

Points covered

• Application of digital technologies to healthcare

• Internet and mobile phone technologies for mental health & behavioural change

• Evidence on Internet based alcohol screening and brief interventions

• Potential to use eBI in healthcare settings eg through GP facilitated access

DYD RCT main results

Mobile phone penetration

Applications of digital technologiesin health care

• Electronic care records (ECRs) • Research using ECRs and

databases• Diagnostics and imaging• Telemedicine and telecare• Virtual healthcare teams• Internet and mobile technologies

for patients